When caring for a client who is at risk for increased intracranial pressure (ICP), which intervention should the nurse implement to assist in stabilizing ICР?
Suction oral cavity frequently to maintain a patient airway.
Keep client's head in a midline position with head raised 30°.
Extend neck with a soft collar placed at base of client's skull.
Turn entire body from side to side at least every 2 hours.
The Correct Answer is B
Rationale:
A. Suction oral cavity frequently to maintain a patent airway: Frequent suctioning increases intrathoracic pressure and can transiently elevate intracranial pressure due to stimulation of the vagus nerve and coughing. Suctioning should be performed only when necessary.
B. Keep client’s head in a midline position with head raised 30°: Maintaining the head midline and elevating it to about 30 degrees promotes optimal venous drainage from the brain and prevents obstruction of jugular venous outflow. This position effectively stabilizes or lowers intracranial pressure while maintaining cerebral perfusion.
C. Extend neck with a soft collar placed at base of client’s skull: Neck extension can impede venous return from the brain, leading to increased intracranial pressure. Proper alignment, rather than extension or flexion, is critical to allow unobstructed cerebral venous drainage.
D. Turn entire body from side to side at least every 2 hours: Repositioning is important for preventing pressure injuries, but abrupt or improper turning can cause surges in intracranial pressure. Movements should be slow and coordinated, with careful head and neck alignment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Hold oral intake until swallow evaluation is done: The client is exhibiting signs of potential dysphagia or airway compromise after extubation. Continuing oral intake could lead to aspiration, airway obstruction, or respiratory complications, making it the most urgent safety concern.
B. Administer PRN IV pain medication: Pain management is important for comfort and to facilitate breathing and mobility, but it does not address the immediate risk of aspiration or airway compromise.
C. Elevate the head of the bed at least 45 degrees: Elevating the head helps reduce aspiration risk and supports respiratory function, but it is a supportive measure that does not replace the need to withhold oral intake until swallowing is formally assessed.
D. Titrate the oxygen to keep saturation above 92%: Maintaining oxygenation is important, but the client’s immediate risk is airway obstruction and aspiration. Oxygen supplementation alone will not prevent these complications if oral intake continues unsafely.
Correct Answer is A
Explanation
Rationale:
A. Measure pulse and blood pressure: Vital signs are the most immediate indicators of hypovolemia. A rapid pulse and hypotension can signal significant blood loss or inadequate circulating volume, allowing the nurse to detect early shock and initiate prompt interventions.
B. Observe skin elasticity: Skin turgor can provide information about fluid status, but it changes more slowly and is less sensitive than vital signs in detecting acute hypovolemia. It is supplementary to more direct hemodynamic assessments.
C. Measure urine output: Urine output is an important measure of perfusion and renal response to hypovolemia, but it reflects fluid status over a longer period and is not as immediately responsive as blood pressure and pulse.
D. Auscultate breath sounds: While monitoring for pulmonary complications is important after thoracic surgery, breath sounds do not provide direct or immediate information about circulating blood volume or hypovolemic status.
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